So during my 0.004 second lunch during the clusterfuck of a day after a holiday, I checked out this article on DrugTopics. Nothing special at face value, however this paragraph really bugged me:
Several factors led Morton’s executives to make the decision to sell most of its retail pharmacy business. “It’s the declining reimbursement environment, mandatory mail-order plans, the closed networks that are starting to become popular across the country, $4 generics programs, and predatory audits,” Morton said.
Both health insurance companies and government programs are slashing reimbursements, according to Morton, a practice that is “not providing enough margins for us to serve patients.” In addition, the purpose of audits conducted by pharmacy benefit managers (PBMs) has changed from detection of fraudulent claims to making extra money for the PBMs, according to Morton. “They are looking for administrative mistakes so they can look to recoup claims. It is a revenue-generating technique,” Morton said.
For those not in the industry, Walgreens has a Pharmacy Benefit Manager called Walgreens Health Initiative. This is similar to how CVS/Caremark work, and the infamous Merck/Medco. Now for those of you who work retail, this whole article makes perfect sense.
- Have your PBM give ridiculous low reimbursement rates to kill the independents.
- Be first in line to “take your failing pharmacy off of your hands for you”
- If they refuse, audit the shit out of them for every little fucking thing until you bankrupt them
- See step 2
Funny, how it’s technically illegal for a bunch of independents to meet to discuss if they are going to take a PBM contract due to antitrust laws, but the major chains and their PBM backers can pull this kind of bullshit. Of course the major chains can bribe (yes, I said bribe…er.. LOBBY) the corrupt government to look the other way.
Having gone through a dozen+ audits, the article is 100% right. The auditors aren’t looking for blatant fraud and abuse, they are looking to generate profits. When you fill an Rx, if you mark a faxed back OK as ‘written’ in your software (instead of a ‘faxed’), that’s grounds for them to take the entire cost of the Rx out of your next check. I bet, with a bit of digging, you’ll find that these auditors actually get an incentive-pay based upon how many ‘errors’ they find on the pharmacy end. I will also bet that Caremark doesn’t audit CVS stores, WHI doesn’t audit Walgreens, and Merck doesn’t audit the Medco mail-order chains. Even if they did audit them, do you really think they would take the money out of their next check? Isn’t that taking money away from themselves?
Sometimes the audits pick up things that are just mistakes, like when you have a Robatussin-DM in your computer as 1 bottle of 273mL and your floater bills 273 bottles by mistake thinking that it’s in the computer as per-cc instead of per-bottle. Those I can see, but taking back the ENTIRE reimbursement over a 28 day supply vs 30 day supply for eye drops is petty and bullshit. We have the Rx, its legit, yet you are back-charging us for the entire amount due to a clerical error (and a stupid one at that). The Rx wasn’t filled fraudulently, and it was filled in good faith with no intent to fraud. However try to argue this point with the auditors and you’ll just get a blank stare and 100 more ‘errors’ that will make your next reimbursement turn into a bill.
So the million dollar question is: Where is APhA in this mess?